Thank you for your consideration to serve the Lord with Child Evangelism Fellowship®. You will need to complete this form in its entirety for your application to be processed. You will need to e-sign your name as agreeing with these items and a parent or guardian must also e-sign with and for a minor (under 18). You will also be required to fill out the Protecting Today's Child forms in order to be considered into the program.

If you have questions or need assistance, please contact us at (818) 349-9883 or cefsoutherncalifornia@gmail.com.

Application Deadline is June 1, 2019.

Personal Information- Part A

Please make sure you have all required information before starting the application process as you will not be able to save your information at a later time.

Full Legal Name
*

First Name Middle Name Last Name

Nickname

If you go by a name other than your full first name, like Will instead of William.

CEF Chapter Name
*

I am a
*

New Student Returning Student

If returning student, how many times have you attended CYIA?

Gender
*

Male Female

Cell Phone Number
*

-
Area Code Phone Number

Home phone
*

-
Area Code Phone Number

Best Phone to contact you
*

Cell Home Phone

Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

E-mail
*

Confirmation Email

Name of Parent/ Guardians if under 18

Age Now
*

Birth Date
*

Month Day Year

Year in School as of January 2018
*

School Name

Graduation Year

T-Shirt Size (in adult men's sizes
*

How did you find out about CYIA?

Christian Life- Part B

God's been working in your life, and we'd like to hear about it!

Your Relationship With God

Why should (shouldn't) God allow you into heaven?
*

Please share how you are growing in your relationship with Jesus Christ. How is God working in your life right now?
*

Medical Information- Part D

If you have any medical or physical conditions that may require accommodation during training week or our summer ministries (including 5-Day Clubs, and fair ministries), please explain using the text below or contact CEF State office at 818-349-9883 or cefsoutherncalifornia@gmail.com.

Additional medical explanation box.

Emergency Contact Information

Primary Contact

Name of Primary Emergency Contact
*

Relation to student
*

Home Phone
*

-
Area Code Phone Number

Cell Phone
*

-
Area Code Phone Number

Work Phone

-
Area Code Phone Number

Secondary Emergency Contact Information

Name of Secondary Emergency Contact
*

Relation to student
*

Home Phone
*

-
Area Code Phone Number

Cell Phone
*

-
Area Code Phone Number

Medical Care Release

If a minor is applying, I am the parent/guardian of the above-named student.

I hereby give full permission for emergency medical treatment for my child while he/she is in the care of Child Evangelism Fellowship of Southern California, Inc. I understand that necessary precautions will be taken to ensure my child's safety while participating in the Christian Youth in Action® program, including 5-Day Club® and related activities.

If you are a minor (17 and under), your parent needs to sign below to indicate that you are in agreement with the above statement. If you are 18 and older, please sign below to indicate that you are in agreement with the above statement.

Signature-use your mouse to enter your signature

Enter Date

-
Month
-
Day Year

Medical Insurance Information
*

Carrier Policy No. Subscriber's Name Health Group No.

No Insurance

Check here ONLY if you do NOT have coverage under medical insurance.

Waiver/ Release- Part E

Student's Name

Travel Waiver for Minors

Item number six of the Child Evangelism Fellowship (CEF®) USA Child Protection Policy fact sheet states, "Even when ministry to children is not taking place, an additional adult or minor must be present when two workers are together and one is a minor, unless the minor’s parent or guardian has signed a waiver."

I understand that there may be occasions when my child may be traveling from location to location in the company of only one adult of legal age.Therefore, I, the parent or legal guardian of above-named student, a minor, hereby waivethe above requirement for this minor and give my permission for him/her to travel and serve with Child Evangelism Fellowship without being accompanied by two or more adults at any given time.

Travel Waiver (choose one)
*

Liability Release

"In the unlikely event that my child (or myself if 18 or older) is injured while participating in activities at Christian Youth In Action®, 5-Day Club® and other official CEF™ activities or in route to such activities, my child and I relinquish all rights to recover damages for any and all injuries sustained by my child (or myself). Inconsideration for CEF granting my child (or myself) permission to participate at CEF activities, I herebyrelease Child Evangelism Fellowship of Southern California, its employees and volunteers fromliability for injuries occurring in CEF activities."

"I further acknowledge that my child (or myself) is responsible to fasten his/her seatbelt and to abide by all traffic laws while involved in CEF activities or in route to such activities."

Liability Release (choose one)
*

Photography and Video Release

Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photos or videos. I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.

Photography and Video Release (Choose one)
*

Full Name of Applicant
*

First Name Last Name

E-mail

Phone Number
*

-
Area Code Phone Number

Parent or Guardian Signature or Applicant over 18
*

CYIA Agreement:

As a CYIA’er for CEF of Southern California, I shall strive to:

Attend pre-training with my local chapter.

Model the Christian lifestyle, whether in class and elsewhere in my relationships with children, CEF representatives, or CYIA team members.